Extracorporeal Shock Wave Therapy for Treating Foot Ulcers in Adults With Type 1 and Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Physiotherapeutic Interventions in Diabetic Foot Ulcer Management: A Case Report

Diabetic foot ulcers (DFUs) represent prominent complications arising from diabetes mellitus, characterized by the development of severe and persistent wounds involving the loss of epidermal and/or dermal layers, with the potential to extend into subcutaneous and underlying tissue structures. In the presented case, a 62-year-old male patient presented with complaints of pain and the emergence of blisters on the right foot, marked by an insidious onset and gradual progression in size, ultimately leading to ulcer formation subsequent to blister rupture. The patient had a medical history spanning 25 years of diabetes mellitus, accompanied by diminished range of motion and muscle strength in the affected foot. The primary goals in the management of DFU encompass addressing muscular weakness, skin manifestations, and any associated underlying health comorbidities. Central to this management approach lies the incorporation of physical therapy and rehabilitation modalities. The rehabilitation regimen designed for the patient was tailored to include targeted resistance exercises, infrared radiation therapy, and sensory integration therapy. Outcome measures, including the Numeric Pain Rating Scale (NPRS), World Health Organization Quality of Life questionnaire (WHO-QOL), and Diabetic Foot Self-Care Questionnaire (DFSQ-UMA), demonstrated substantial improvements, reflecting enhanced activities of daily living. This case underscores the pivotal role of incorporating physiotherapy into a comprehensive multidisciplinary approach for optimizing the management of DFUs. Such integration aims to improve patient outcomes and overall quality of life.

Extracorporeal Shockwave Therapy (ESWT) in the Management of Diabetic Foot Ulcer: A Prospective Randomized Clinical Trial

Diabetic foot ulcer (DFU) is the most common cause of prolonged hospitalization with a high cost of care due to unsatisfactory outcomes with the current mode of therapy. Extracorporeal shockwave therapy (ESWT) is a new technology in the care of nonhealing wounds. The study's main objective was to compare the healing parameters of DFUs between patients undergoing the standard of care (SOC) alone and ESWT + SOC. The secondary objective was to assess inflammatory markers in both study groups. The study was designed as a single-center, randomized trial to provide evidence on the effects of ESWT on DFU healing. Informed consent was obtained from all participants before enrolment. Forty-eight participants were recruited, enrolled, and randomly allocated into the 2 study groups. Twenty-five patients were allocated to the ESWT + SOC group, and 23 patients were allocated into the SOC-only group for a treatment period of 6 weeks. The univariate binary analysis showed more patients with healed DFU in the ESWT + SOC group than the SOC-only group at 6 weeks, though the difference did not reach statistical significance (OR = 3.2, p = .07). The adjusted multivariate binary analysis confirmed this finding; however, the effect size did not reach statistical significance at 6 weeks (OR = 3.9, p = .08). The level of circulating inflammatory markers was similar in both groups of patients. It is the author's opinion that there is a potential benefit of ESWT on diabetic wound healing with further research warranted to determine its role in treatment of DFU. A larger trial with a more extended treatment period is, however, needed to substantiate our findings.

Application of extracorporeal shockwave therapy to improve microcirculation in diabetic foot ulcers: A prospective study

Extracorporeal shockwave therapy (ESWT) can induce wound healing by increasing tissue microcirculation. However, studies on the effect of ESWT on enhancing tissue microcirculation in diabetic foot ulcer (DFU), particularly on when the microcirculation increases after ESWT application, are still lacking. Therefore, we aimed to examine the effectiveness of ESWT in promoting microcirculation in DFU patients in a time-dependent manner. We included 50 feet of 25 patients with type 2 diabetes mellitus and Wagner grade I to II DFU in this study. The affected feet were used as the ESWT group and the unaffected contralateral feet were used as the control group. ESWT was performed in 3 sessions per week for a total of 3 weeks. Transcutaneous partial oxygen pressure (TcPO2) was used to evaluate the tissue microcirculation. The TcPO2 level (>43 mm Hg) in the ESWT group was recovered by the 2nd week of treatment, and statistical significance (P < .05) was demonstrated at the same time. From the 2nd week of ESWT, a significant increase in TcPO2 was observed in Wagner grade I and II DFU. These findings imply that the ESWT may improve microcirculation in patients with Wagner grades I to II DFU. However, this impact requires at least 2 weeks or more than 6 sessions. For better comparison, further studies with larger clinical groups and extended period are needed.

Physiotherapeutic interventions in the treatment of patients with diabetic foot ulcers: a systematic literature review

BACKGROUND

Diabetic foot ulcers are chronic wounds that are difficult to heal, with a high rate of recurrent hospitalizations. Due to its multifactorial complexity, treatment must be considered as multidisciplinary, with adjuvant therapy required to aid the healing process.

OBJECTIVES

To identify physiotherapeutic interventions for the treatment of diabetic foot ulcers through a systematic literature review.

DATA SOURCES

PubMed, Cochrane Library, SciELO and Web of Science were searched in April 2020.

STUDY SELECTION OR ELIGIBILITY CRITERIA

The inclusion criteria for this review were: randomised controlled trial published in the last 5 years; written in Portuguese, English or Spanish; subjects aged> 18 years with a diagnosis of diabetic foot ulcers; and physiotherapeutic intervention in combination with multidisciplinary wound management. The methodological quality was assessed using the PEDro scale.

RESULTS

Eight studies were included. Physiotherapists can treat diabetic foot ulcers using therapeutic exercises, electrotherapy, manual therapy and assistive technologies. All physiotherapeutic interventions were adjuvant to standard treatment for wounds provided by other health professionals. The main outcomes were wound size and healing time, with highly favourable results obtained for the experimental groups compared with the control groups.

CONCLUSIONS

Therapeutic exercise, electrotherapy, manual therapy and assistive technologies are physiotherapeutic modalities that, when combined with standard treatment, have been shown to be beneficial in the healing of diabetic foot ulcers.

[Diabetic neuropathy and diabetic foot syndrome (update 2023)]

These are the guidelines for diagnosis and treatment of diabetic neuropathy and diabetic foot.The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy, including the complex situation of the diabetic foot syndrome. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotor neuropathy, are provided. The needs to prevent and treat diabetic foot syndrome are summarized.

Evolving spectrum of diabetic wound: Mechanistic insights and therapeutic targets

Diabetes mellitus is a chronic metabolic disorder resulting in an increased blood glucose level and prolonged hyperglycemia, causes long term health conse-quences. Chronic wound is frequently occurring in diabetes patients due to compromised wound healing capability. Management of wounds in diabetic patients remains a clinical challenge despite many advancements in the field of science and technology. Increasing evidence indicates that alteration of the biochemical milieu resulting from alteration in inflammatory cytokines and matrix metalloproteinase, decrease in fibroblast and keratinocyte functioning, neuropathy, altered leukocyte functioning, infection, etc., plays a significant role in impaired wound healing in diabetic people. Apart from the current pharmacotherapy, different other approaches like the use of conventional drugs, antidiabetic medication, antibiotics, debridement, offloading, platelet-rich plasma, growth factor, oxygen therapy, negative pressure wound therapy, low-level laser, extracorporeal shock wave bioengineered substitute can be considered in the management of diabetic wounds. Drugs/therapeutic strategy that induce angiogenesis and collagen synthesis, inhibition of MMPs, reduction of oxidative stress, controlling hyperglycemia, increase growth factors, regulate inflammatory cytokines, cause NO induction, induce fibroblast and keratinocyte proliferation, control microbial infections are considered important in controlling diabetic wound. Further, medicinal plants and/or phytoconstituents also offer a viable alternative in the treatment of diabetic wound. The focus of the present review is to highlight the molecular and cellular mechanisms, and discuss the drug targets and treatment strategies involved in the diabetic wound.

Effect of Botulinum Toxin Injection and Extracorporeal Shock Wave Therapy on Nerve Regeneration in Rats with Experimentally Induced Sciatic Nerve Injury

This study was designed to compare the roles of botulinum neurotoxin A (BoNT/A) and extracorporeal shock wave therapy (ESWT) in promoting the functional recovery and regeneration of injured peripheral nerves. A total of 45 six-week-old rats with sciatic nerve injury were randomly divided into two experimental groups and one control group. The experimental groups received a single session of intranerve BoNT/A or ESWT immediately after a nerve-crushing injury. The control group was not exposed to any treatment. Differentiation of Schwann cells and axonal sprouting were observed through immunofluorescence staining, ELISA, real-time PCR, and Western blot at 3, 6, and 10 weeks post-nerve injury. For clinical assessment, serial sciatic functional index analysis and electrophysiological studies were performed. A higher expression of GFAP and S100β was detected in injured nerves treated with BoNT/A or ESWT. The levels of GAP43, ATF3, and NF200 associated with axonal regeneration in the experimental groups were also significantly higher than in the control group. The motor functional improvement occurred after 7 weeks of clinical observation following BoNT/A and ESWT. Compared with the control group, the amplitude of the compound muscle action potential in the experimental groups was significantly higher from 6 to 10 weeks. Collectively, these findings indicate that BoNT/A and ESWT similarly induced the activation of Schwann cells with the axonal regeneration of and functional improvement in the injured nerve.

Novel therapeutic targets for diabetes-related wounds or ulcers: an update on preclinical and clinical research

INTRODUCTION

Diabetes-related wounds, particularly diabetes-related foot ulcers, are mainly caused by lack of foot sensation and high plantar tissue stress secondary to peripheral neuropathy, ischemia secondary to peripheral artery disease, and dysfunctional wound healing. Current management of diabetes-related wounds involves the offloading of high foot pressures and the treatment of ischemia through revascularization. Despite these treatments, the global burden of diabetes-related wounds is growing, and thus, novel therapies are needed. The normal wound healing process is a coordinated remodeling process orchestrated by fibroblasts, endothelial cells, phagocytes, and platelets, controlled by an array of growth factors. In diabetes-related wounds, these coordinated processes are dysfunctional. The past animal model and human research suggest that prolonged wound inflammation, failure to adequately correct ischemia, and impaired wound maturation are key therapeutic targets to improve diabetes-related wound healing.

AREAS COVERED

This review summarizes recent preclinical and clinical research on novel diabetes-related wound treatments. Animal models of diabetes-related wounds and recent studies testing novel therapeutic agents in these models are described. Findings from clinical trials are also discussed. Finally, challenges to identifying and implementing novel therapies are described.

EXPERT OPINION

Given the growing volume of promising drug therapies currently under investigation, it is expected within the next decade, that diabetes-related wound treatment will be transformed.

[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

Focused Extracorporeal Shockwave Therapy in Physical Medicine and Rehabilitation

Purpose of Review

Focused extracorporeal shockwave therapy (fESWT) is a physical treatment modality developed over the last 25 years for musculoskeletal indications. It has many indications in the field of physical medicine and rehabilitation (PM&R) and is effective, time-efficient, and cost-efficient. This review focuses on basics and on clinical indications as well as on significant trends in fESWT.

Recent Findings

In PM&R, stimulation of healing processes in tendons, surrounding tissue, and bones via mechanotransduction seems to be a relevant biological effect. The International Society for Medical Shockwave Treatment (ISMST) describes different types of indications (such as approved standard indications—in accordance with most scientific evidence—like calcifying tendinopathy of the shoulder, plantar fasciitis lateral epicondylopathy of the elbow, greater trochanter pain syndrome, patellar tendinopathy, Achilles tendinopathy and bone non-union, common empirically tested clinical uses, exceptional or expert indications, and experimental indications).

Summary

fESWT is a relevant treatment option in PM&R and regenerative medicine. In recent years, historical paradigms (for example, application in cancer patients) have changed and new indications (such as nerve regeneration, myofascial trapezius syndrome, low back pain, dermatosclerosis, and lymphedema) are supported. Future translational research should focus on establishing actual exceptional indications and experimental indications for clinical routine.

Diabetic Foot Ulcers: Appraising Standard of Care and Reviewing New Trends in Management

Diabetic foot ulcers (DFU) are one of the most common diabetes complications and are associated with significant morbidity and mortality. Current DFU standard of care (SOC) involves four principles: (1) pressure relief, (2) debridement, (3) infection management, and (4) revascularization when indicated. Despite the current SOC, many DFU persist, warranting a new approach for the management of these complex wounds. This review aims to summarize the current SOC as well as the latest trends in adjunctive therapies that may become the new SOC in DFU management. These include negative pressure wound therapy and hyperbaric oxygen therapy, bioengineered skin substitutes, growth factors, shockwave therapy, and several others. These novel therapies have shown significant DFU clinical improvement among subsets of DFU patients. However, much of the literature comes from smaller trials with inconsistent patient selection and outcomes measured, making it difficult to assess the true clinical benefit of these treatments. While novel therapies are promising for the interdisciplinary approach to DFU management, many still lack sufficient evidence, and their efficacy remains to be determined.